Managed Long Term Care Partial Capitation Plan Lock-in

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Frequently Asked Questions (FAQs)

August 4, 2021

Please consult all previously released materials in conjunction with the following FAQs. If you have any questions regarding this information, please send an email to the following address:

Q1. Does Managed Long Term Care Partial Capitation (MLTCP) Lock-in policy impact existing MLTCP enrollees? Meaning effective 12/1/2020 will all current MLTCP enrollees be allotted the same 90-day grace period if they wish to switch plans?

A1. MLTCP enrollees that were enrolled in MLTCP plan prior to December 1, 2020 will not be subject to lock-in with their current plan until they transfer on or after December 1, 2020.

Q2. Does the MLTCP Lock-in policy apply to MLTC exempt populations, if they choose to enroll into an MLTCP plan?

A2. No, MLTC Exempt populations are not subject to lock-in and may transfer from one MLTCP to another MLTCP at any time.

Q3. Does the MLTCP Lock-in policy apply to MLTC voluntary populations?

A3. No, MLTC voluntary populations are not subject to lock-in and may transfer from one MLTCP to another MLTCP at any time.

Q4. What telephone number should MLTCP plans use or direct enrollees to use to contact New York Medicaid Choice (NYMC) for the purpose of a Good Cause request?

A4. The designated phone number Plans should provide to their enrollees to contact NYMC for purpose of Plan transfer is 1-888-401-6582 (TTY:1-888-329-1541).

Q5. Does the MLTCP Lock-in policy apply to Fully Integrated Duals Advantage for Individuals with Intellectual and Developmental Disabilities (FIDA IDD)?

A5. No, the MLTCP Lock-in Policy does not apply to FIDA-IDD.

Q6. Can an enrollee transfer more than once during their 3-month grace period?

A6. Each time an enrollee transfers to an MLTCP plan their enrollment will begin with a new 90-day grace period.

Q7. If the enrollee does not contact NYMC during their grace period, then the transfer would not be allowed?

A7. NYMC must receive the request to transfer during the grace period from the enrollee. Requests to transfer outside of the grace period would require Good Cause.

Q8. If enrollee contacts an MLTCP to request a transfer during their grace period, what should the contacted MLTCP do to help the enrollee?

A8. The MLTCP should refer the enrollee to NYMC. NYMC will assist the enrollee and document that they have received a request from the enrollee. The enrollee´s request for transfer will be honored when the new plan and the enrollee contact NYMC to process the transfer.

Q9. Can an MLTCP enrollee transfer to another MLTCP plan after their lock-in period ends?

A9. Once the enrollee´s lock-in period has ended the enrollee may transfer to another MLTCP plan at any time and for any reason without Good Cause.

Q10. Will there be a rejection code for MLTCP to MLTCP transfer when the enrollee is locked in? Will the rejection code provide dates to the enrollee´s Lock-in lift?

A10. MLTCP plans will be notified of the rejection via the existing Reject File (R File) process. and will receive reason code M028 (Consumer is Locked-in to Current Plan) in that file. To obtain lock-in dates, MLTCP plans should contact NYMC as this information will not be included in the R File.

Q11. If an MLTCP enrollee attempts to transfer during their grace period but are unable to due to insufficient Medicaid coverage, will Good Cause be granted during enrollee´s lock-in period?

A11. If an MLTCP enrollee requests transfer during their grace period but was not able to complete the transfer request for various reasons, including insufficient Medicaid coverage, NYMC notates the date of request in their system to allow transfers when appropriate.

Q12. What would be an "appropriate” example for Good Cause reason: The enrollee and the plan agree that a transfer is appropriate?

A12. When a situation exists where the current plan and the enrollee agree that it is in the best interest of both parties for the enrollee to transfer to another plan.

Q13. How will NYMC be able to determine the validity of an enrollees claim that the plan failed to provide the appropriate medical care, services or supplies to which the enrollee is entitled as per their Plan of Care (POC)?

A13. NYMC will follow the New York State (NYS) Department of Health´s guidelines regarding POC to determine if the enrollee´s circumstances meet the Department´s criteria for Good Cause. NYMC will consult with the Department if there are any questions.

Q14. For Good Cause reason, "The plan has failed to furnish accessible and appropriate medical care, services or supplies to which the enrollee is entitled as per his/her plan of care", does the current MLTCP plan have to agree to the transfer, in order for the transfer to be approved?

A14. No, this Good Cause reason does not require the agreement of the enrollee´s current MLTC plan to reach a determination.

Q15. How long does an enrollee have to complete and return an MLTC Good Cause packet to NYMC (i.e., does the packet expire after a certain timeline)?

A15. The packet will be reviewed for a determination upon receipt.

Q16. What are the required timeframes for NYMC to provide a determination of the Good Cause request for an MLTCP enrollee?

A16. NYMC has 3 business days to render a determination for an MLTCP Good Cause transfer request. NYMC is required to mail the determination letter within 3 to 5 business days after a determination has been made.

Q17. Is an MLTCP enrollee informed in writing of the Good Cause determination?

A17. Yes, NYMC is required to inform an enrollee in writing of the Good Cause determination.

Q18. If an enrollee wants to transfer from an MLTCP plan to another MLTCP plan during their lock-in period, will NYMC contact the current MLTCP plan to verify if the Good Cause reason is valid?

A18. There are Good Cause reasons where contacting the current MLTCP plan would be required to reach a determination. If required, NYMC will contact the current MLTCP plan via a 3-way call with the enrollee or via a secure email.

Q19. What is the turnaround time from when an enrollee requests a Good Cause packet to when the enrollee receives it from NYMC?

A19. The packet will be mailed within 3 to 5 business days from date of the request.

Q20. Will the current MLTCP plan also receive a Good Cause determination letter?

A20. No, the current MLTCP plan will not receive the Good Cause Approval or Good Cause Denial Letter.

Q21. Will the current MLTCP plan be required to complete any documentation/forms for submission to NYMC to support the processing of Good Cause request for disenrollment?

A21. Upon request from NYMC, the current MLTCP plan may be required to provide supporting documentation during the Good Cause review.

Q22. Who will NYMC contact at the MLTCP plan for the 3-way call? Will plans need to establish a specific contact/department for the 3-way call?

A22. NYMC will contact the enrollee´s MLTCP plan´s Member Service department. The Member Service department would be responsible for connecting the3-way call with the enrollee and NYMC to the appropriate person/department.

Q23. Who is responsible to notify new enrollees of the Lock-in policy at the time of enrollment?

A23. NYMC is required to provide education regarding the MLTCP Lock-in policy. In addition, the MLTCP plan is responsible for educating the enrollee regarding the Lock-in policy upon enrollment.

Q24. Would it be appropriate for the current plan to call NYMC with the enrollee on the phone to initiate an agreed upon disenrollment discussion?

A24. Yes, if the enrollee contacts their current plan to request a disenrollment, the plan can assist their enrollee with contacting NYMC.